Thompson v. Insurance and Benefits Trust

JERRY THOMPSON, PLAINTIFF,v.INSURANCE AND BENEFITS TRUST/COMMITTEE PEACE OFFICERS RESEARCH ASSOCIATION OF CALIFORNIA, PEACE OFFICERS RESEARCH ASSOCIATION OF CALIFORNIA, AND DOES 1 TO 100, DEFENDANTS.

The opinion of the court was delivered by: Frank C. Damrell, Jr. United States District Judge

MEMORANDUM AND ORDER

This matter is before the court on the parties' cross-motions for judgment on the administrative record, pursuant to Federal Rule of Civil Procedure 52,*fn1 arising out of defendants Insurance and Benefits Trust of Peace Officers Research Association of California and Peach Officers Research Association of California's (collectively, "defendants" or "PORAC") denial of plaintiff Jerry Thompson's ("plaintiff") claim for long-term disability ("LTD") benefits.*fn2 For the reasons set forth below, the court finds that the proper standard of review of this matter is abuse of discretion, as opposed to de novo, and thereunder, the court finds that PORAC did not act arbitrarily or capriciously in denying plaintiff's LTD benefits claim. As such, the court DENIES plaintiff's motion for judgment in his favor and HEREBY GRANTS judgment in favor of PORAC.

BACKGROUND

A. The Plan

Plaintiff is a participant in a long term disability benefit plan (the "Plan") sponsored by the Insurance and Benefits Trust of Peace Officers Research Association of California. The Plan is governed by the Employee Retirement Income Security Act of 1974 ("ERISA"). (Pl.'s Compl., filed Mar. 25, 2008, ¶ 6.) PORAC is responsible for payment of benefits during the "Self-Funded Period," which is defined as "[t]he first 5 years of each period of continuous Disability, and the period after the end of the Maximum Benefit Period during which [long term disability] Benefits are payable under the Lifetime Disability Benefit provision." (Administrative Record ["AR"], Ex. A to Jimenez Decl. [Docket #29], filed Aug. 10, 2009, at P00434.) The Plan is funded during the self-funded period by contributions from Plan participants. (Jimenez Decl., ¶ 3.) PORAC derives no financial benefit in the event of a denial of a participant's claim for benefits under the Plan. (Id. at ¶ 4.) Standard Insurance Company provides insurance benefits to the Plan, but only for the period of time following the Self-Funded Period. Under the Plan, PORAC is responsible for managing the Plan and determining eligibility for benefits during the Self-Funded Period. In connection with disabilities relating to musculoskeletal and connective tissue, the Plan limits benefits to a maximum of 24 months. (AR: P00436.)

In pertinent part, the Plan defines disability as follows: You are Disabled if you meet one of the following definitions during the period it applies:

A. Own Occupation Definition of Disability; [or]

B. Any Occupation Definition of Disability . . .

Own Occupation means any employment, business, trade, profession, calling or vocation that involves Material Duties of the same general character as your regular and ordinary employment with the Employer. Your Own Occupation is not limited to your job with your Employer.

Material duties means the essential tasks, functions and operations, and the skills, abilities, knowledge, training and experience, generally required by employers from those engaged in a particular occupation.

A. Own Occupation Definition of Disability During the Benefit Waiting Period and the Own Occupation Period you are required to be Disabled only from your Own Occupation.

You are Disabled from your Own Occupation if, as a result of Physical Disease, Injury, Pregnancy or Mental Disorder, you are unable to perform with reasonable continuity the Material Duties of your Own Occupation. However, you will not be considered to be disabled from your Own Occupation if you are working in a light duty position for the same employer for which you were working when you became disabled, and your employer is paying you the same wages paid to you immediately before you became disabled.

B. Any Occupation Definition of Disability During the Any Occupation Period you are required to be Disabled from all occupations.

You are Disabled from all occupations if, as a result of Physical Disease, Injury, Pregnancy or Mental Disorder, you are unable to perform with reasonable continuity the Material Duties of any gainful occupation for which you are reasonable fitted by education, training and experience. (AR: P00439-440.)*fn3

B. Plaintiff's Medical History Leading Up to His Claim for Plan Benefits

Plaintiff was employed by San Joaquin County as a Correctional Officer. "Employees of this class are responsible for following clearly established procedures in receiving prisoners, maintaining discipline and preventing escapes." (AR: P00244.) Employees in this position are required to have the ability to:

Supervise inmates engaged in a variety of activities; store, issue and account for recreation equipment, clothing, cleaning supplies and other items; understand and interpret rules and regulations; keep records and prepare reports; remain alert at all times and react quickly and calmly in emergency situations; follow oral and written instructions; establish and maintain effective working relationships with others; learn to utilize data terminals as required. (AR: P00245.)

On July 15, 2004, plaintiff was injured while running to break up a fight between prisoners at the county jail. (AR: P0024, P00232.) Prior to this, plaintiff fell off a wall while engaged in training activities in June 2004. He experienced some minor pain at the lumbosacral portion of the spine at that time, as well as a cramping sensation in his right lower extremity, but he did not seek medical attention as a result of this incident and continued to work. (AR: P00179.)

On July 15, 2004 while he was running, plaintiff fell and landed on the right side of his body. More specifically, he claims that while running, he experienced a cramp in his right leg that caused him to fall to the concrete sidewalk. When he rose, he reported severe pain on the back of his leg. (AR: P00408.) On that same date, plaintiff filled out an "Employee's Claim for Workers' Compensation Benefits," stating that his right elbow and leg were injured. (AR: P00226.)

Plaintiff saw Dr. Gregory Rosellini for his claimed injuries on July 15, 2004. In his "Doctor's First Report of Occupational Injury or Illness" on that date, Dr. Rosellini diagnosed plaintiff with a "muscle strain hamstring" and "abrasions-multiple." (AR: P00408). Plaintiff was given an ACE wrap, crutches, Tylenol #3 with codeine and Motrin. Future treatment was noted as "possibly PT [physical therapy]". Dr. Rosellini noted that plaintiff was authorized to return to work on July 19, 2004. (Id.)

A July 16, 2004 Primary Treating Physician's Progress Report referred to a hamstring strain, with plaintiff reporting mild but much improved pain. (AR: P00407.) Plaintiff was authorized to return to full duty on July 22, 2004. (Id.)

Plaintiff was thereafter seen on August 9, 2004 by a Dr. Zuniga. He reported that he was feeling better but still had some pain in the right hamstring. (AR: P00403.) A Physician's Verification of Employee Illness form dated November 2, 2004 authorized plaintiff to return to work with restrictions (no running, jumping or altercations) on November 2, 2004, and to return to work without restrictions starting December 2, 2004. (AR: P00379, P00383.)

Plaintiff continued to report right knee pain and that his knee was "giving out" during a December 14, 2004 doctor's visit. He was authorized to return to work full time January 29, 2005. (AR: P00377-378.) The return to work date was extended to February 22, 2005 during a January 31, 2005 doctor's visit. (AR: P00376.)

A magnetic resonance imaging ("MRI") test of the right knee was recommended. (AR: P00368.) Plaintiff underwent the right knee MRI on February 11, 2005. The radiologist opined that plaintiff's right knee was normal. (AR: P00370.)

On March 28, 2005, plaintiff stated that he had started "TRT" or "trauma release therapy." (AR: P00363, P00365.) His subjective complaints at that time were that his right hip and thigh went numb and that his right knee "pops." He also referred to "mild back pain" and right calf cramps. (AR: P00365.) He was nevertheless advised to continue on full work duty and to continue with trauma release therapy. (AR: P00363.)

Plaintiff again complained of recurrent lower back pain in an April 18, 2005 doctor's visit (as well as right knee pain). An MRI of the lumbosacral spine was suggested and Naprosyn and Soma were recommended for pain. (AR: P00362.) Light duty was recommended during an April 22, 2005 doctor's visit. (AR: P00360.) Plaintiff was allowed to return to work with restrictions (no lifting over 10 pounds and no prolonged standing over 3 hours) on April 22 and directed to return to work without restrictions on May 23, 2005. (AR: P00357.)

A May 13, 2005 progress report notes that plaintiff may return to work with restrictions on May 13, 2005 (no lifting over 10 lbs and no prolonged standing over 3 hours) and may return to work without restrictions on June 14, 2005. (AR: P00350.)

On August 4, 2005, plaintiff saw Dr. Moris Senegor. Plaintiff reported that since July 15, 2004, he had been experiencing low back pain and right leg pain radiating down the leg towards the foot. He also reported tingling paresthesias over the right lateral calf and in the foot. He indicated that he had so far received only some massage therapy which had not helped, that he worked full time from the time of his injury until December 2004 and that he had worked on and off since then. (AR: P00347.) Dr. Senegor's impression was that plaintiff's symptoms were secondary to degenerative disc disease, and he recommended physical therapy. He recommended temporary total disability ("TTD") for worker's compensation purposes for six weeks and stated that if physical therapy fails, epidural steroid injections would be considered. Dr. Senegor also noted that the MRI scan reflected "no nerve compression." (AR: P00338-339.)

Plaintiff again saw Dr. Senegor on October 19, 2005 and Dr. Senegor's report noted that "[t]he patient's symptoms remain unchanged." Dr. Senegor advised plaintiff that he would extend plaintiff's TTD for six weeks at which time he would reevaluate him. (AR: P00303.) Between that date and November 30, 2005, plaintiff had four physical therapy sessions. Dr. Senegor stated on November 30, 2005 that the outcome of that physical therapy was "not quite clear as of yet." Plaintiff reported ongoing low back pain and right leg pain and stated that he was taking "narcotic medications." Dr. Senegor stated he would see plaintiff in another six weeks. (Id.)

A December 29, 2005 Progress Report for the period November 22, 2005 through December 28, 2005, from Darlynne D. Giorgi, the nurse consultant assigned to plaintiff's worker's compensation case states, in relevant part, that: "Thompson was reevaluated by Dr. Senegor on November 30, 2004 . . . Dr. Senegor is continuing Mr. Thompson at TTD for an additional 6 weeks since he has only completed four physical therapy sessions. Physical therapist at Oak Valley Physical Therapy facility indicates that Mr. Thompson's weight is a factor in his slow progress. He continues to report low back discomfort, and his gains in physical therapy are short lived . . . . I telephoned Dan Pipel at Oak Valley Physical Therapy facility . . . He ...

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